The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 17: Ethical IssuesThe Principle of ProportionalityThe rule of double effect is somewhat controversial. Not every medical ethicist believes thatit is as26importantpicasto medical practice as we have suggested. 15 But the fourth condition in therule of double effect—the one that specifies that a physician must act for a proportionatelygrave reason—is widely accepted even by those who reject the rule of double effect. Thereforeit can and should be considered on its own terms. So understood, we shall refer to it as theprinciple of proportionality.This principle is very important to palliative medicine. A number of writers have appealed tothis principle in their explorations of when, and under what conditions, a physician’s obligation12, 25to relieve terminal suffering may justifiably override his or her obligation to prevent harm.According to Timothy Quill, Bernard Lo, and Dan Brock, for example, the concept of proportionalityrequires that the risk of causing harm bear a direct relationship to the danger and immediacyof the patient’s situation and expected benefit of the intervention. 25 These writers haveproposed the following formulation of the proportionality principle for regulating physicians’use of vigorous pharmacological measures in the palliative care setting:[T]he greater the patient’s suffering, the greater risk the physician can take ofpotentially contributing to the patient’s death, so long as the patient understandsand accepts the risk. 25This formulation of the principle, however, does not specify what type (or types) of sufferingjustifies a physician’s use of pharmacological interventions to treat suffering. It simply instructsphysicians to sum up the total amount or intensity of the suffering their patients are experiencing.In this formulation all terminal suffering is on equal footing and it is all subject to therequirements of proportionality.This principle of proportionality can be extended and refined by considering the theoreticalideal of promoting patient well-being and distinguishing between different kinds of pain andsuffering and the different sorts of therapeutic interventions they may require. For example, apatient living with HIV/AIDS who is nearing the end of life may experience suffering that resultsfrom his terminal condition as well as suffering that results from his own reflection on his condition.Suppose, for example, that this patient blames himself for his illness and this causes himgreat inner turmoil. The resulting psychosocial suffering may be as intense as, or even moreintense than, the pain and suffering caused by his underlying physiological condition. It wouldbe a mistake, however, simply to sum up his suffering as if it were all the same. Some of thesuffering that this patient experiences—what we have referred to here as psychosocial suffering—isnot appropriately managed by aggressive pharmacological measures. Unless thesethoughts are symptoms of major depression, the patient’s psychosocial suffering should be managedby appropriate psychological or spiritual counseling.This point is important for all patients in need of palliative care, but it has particular force whenapplied to patients living with HIV/AIDS. Recent studies suggest that a high proportion of patientsliving with HIV/AIDS who desire euthanasia or assisted suicide do so for reasons otherthan the need to avoid pain. 6, 26 Depression, hopelessness, psychological anguish, distress causedby stigmatizing events related to their HIV status, and loss of community have been identified askey factors contributing to the suffering of these patients. 26 These forms of suffering, however,are not appropriately managed by high-dose narcotics. 14, 27 This strongly suggests that physi-356U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau